CMS/EIP Fiscal Report Center: 07
Services beginning 04/01/2010 ending 06/30/2010 Date of Report:08/18/2010 Page: 1
Payclass Filters:TPIN
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 1 1.00 0.00 0.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 11 30.50 1128.50 37.00
Subtotal (Total Children Is Unduplicated) 12 31.50 1128.50 35.83
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.00 10.62 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.00 8.83 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.00 10.80 10.80
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.00 21.79 21.79
AUDE-92585-AUD EVOKED RESPONSE (DIAG) 1 1.00 54.38 54.38
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 2.00 63.62 31.81
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 14.00 1050.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.00 150.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 5.00 375.00 75.00
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.00 150.00 75.00
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.00 291.00 48.50
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.00 48.50 48.50
SENS-V5014TS-HEARING AID REPAIR IN-OFFICE 1 4.00 60.00 15.00
SPCH-92506-SPEECH EVAL BY LICENSED SLP 18 19.00 921.50 48.50
Subtotal (Total Children Is Unduplicated) 41 60.00 3216.04 53.60
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 148.50 7425.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 30 144.00 9774.72 67.88
OCCT-97530HM-OT SESSION BY OT ASST 1 1.00 54.32 54.32
PHY-97110-PT SESSION BY LICENSED PT 13 48.25 3208.33 66.49
SENS-V5264-EARMOLD 1 2.00 37.44 18.72
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 48 241.25 16334.90 67.71
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 1 100.00 50.00 0.50
Subtotal (Total Children Is Unduplicated) 79 685.00 36884.71 53.85
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Total 776.50 41229.25 53.10
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Number of Children (Unduplicated) With at Least One Service 114
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Center 07
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 57 224.25 12724.83 12724.83
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
210 552.25 28504.42 0.00
Other 0 0.00 0.00 0.00
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Total 267 776.50 41229.25 12724.83